If yes, do you have unconditional clearance to serve on this service trip?

Yes No

Do you have any chronic ailment or physical disability that might prevent you from rigorous activities, high altitudes, or extreme temperatures?
*

Yes No

If yes, please explain.

Do you have dietary restrictions?
*

Yes No

If yes, please explain.

Have you been treated or hospitalized for a mental or emotional condition?
*

Yes No

If yes, please explain.

Do you regularly use any prescription medications?
*

Yes No

If yes, please explain.

Please list any food or medical allergies that you have.
*

None

Anything else we should know about your medical history?
*

References

Please list two (2) references that we may contact. Your references will receive an email requesting their reference upon submission to this application.

Personal Reference

Please choose someone that knows you well, but is NOT related to you.

Personal Reference Name:
*

First Name Last Name

Relationship to Reference
*

E-mail of Personal Reference
*

Phone Number
*

-
Area Code Phone Number

Years Known:
*

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Professional Reference

This can be an employer, colleague, professor, pastor, etc.

Professional Reference Name:
*

First Name Last Name

Relationship to Reference
*

E-mail of Professional Reference
*

Phone Number
*

-
Area Code Phone Number

Years Known:
*

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Release Forms and Contract

Release of Liability and Medical Authorization

(Release of Liability and Permission Regarding Medical Care)

INTRODUCTION//

This is a release of liability and an authorization regarding medical care. By signing below, I am agreeing to release wine to water and other parties from liability. I am also granting permission to wine to water to seek and obtain medical care in the event of my illness or injury. I have therefore been advised to read this document carefully and understand that I have the opportunity to consult with an attorney before signing.

It is my understanding that participation in this trip is a privilege. In consideration for the privilege of participating in this trip, I am signing this Release of Liability and Medical Authorization (Release). I acknowledge that I am a competent person acting on my own free will and that participation in this trip may involve certain risks of physical injury, illness or death, including risks of which I may not presently be aware, and I hereby agree to assume such risks.

RELEASE AND INDEMNIFICATION//

I hereby agree to release, discharge, waive and hold harmless Wine to Water, members of its Board of Directors, its officers, employees, members, volunteers, agents, representatives, successors, assigns and insurers, its sponsoring organizations and affiliates, as well as members of their Board of Directors and their officers, employees, members, volunteers, agents, representatives, successors, assigns and insurers, whether past, present or future (collectively, the Released Parties), from and against any and all claims, demands, losses, damages, and liabilities (including claims for personal injury, death, property damage and economic losses), whether known or unknown, foreseen or unforeseen, future or contingent, whether based on tort, contract, statute or any other theory WITH THE EXCEPTION OF claims, demands, losses, damages, and liabilities arising solely out of the exclusive gross negligence or willful misconduct of a Released Party, which are not hereby released, discharged or waived as to that Released Party.. I further covenant not to sue any of the Released Parties in connection with any of the released claims, demands, losses, damages, or liabilities described above. I further agree to indemnify, save, and hold harmless the Released Parties from any and all claims, demands, losses, damages, and liabilities (including claims for personal injury, death, property damage and economic losses) for indemnity, contribution or otherwise, arising from my participation in this trip, as may be asserted by a third party (defined as any party other than the Released Parties or me), except to the extent such a claim might be based upon the sole and exclusive gross negligence or willful misconduct of one or more of the Released Parties.

AUTHORIZATION OF MEDICAL CARE//

I attest and certify that there are no known medical conditions that would prevent me from participating. I understand and acknowledge that Wine To Water, together with the sponsoring organizations, provides foreign trip insurance coverage as a part of the cost of the trip. I understand and acknowledge that the provided coverage is not intended to take the place of a personal or group health insurance plan and may not specifically apply in every event of illness, injury, death, or damage to my property that may occur during participation on this trip.

In case I am in need of any medical or surgical treatment to protect my health and welfare while participating in this trip, I authorize and agree to allow any authorized agent or employee of Wine to Water, to consent to and authorize the administering of such necessary medical and/or surgical treatment. I acknowledge and agree that the release of liability, hold harmless, and indemnification provisions set forth in Section 2 above shall apply to any authorization and consent to medical or surgical treatment on my behalf made by Wine to Water or its authorized agents or employees. If I am a minor, I understand that efforts will be made to contact my parent/guardian before these actions are taken.

MEDIATION/ARBITRATION//

Wine to Water and I agree that should a claim or dispute arise from my participation in this trip, the parties to the dispute shall attempt to resolve the dispute via mediation. If mediation does not resolve the dispute, the dispute shall be resolved by binding arbitration pursuant to the Federal and North Carolina arbitration acts. The venue for such mediation and arbitration shall be Boone, North Carolina, or such other location agreed upon by both parties. The arbitration shall be conducted pursuant to the rules of the American Arbitration Association, as in effect when the arbitration is commenced. Judgment upon an arbitration award may be entered in any court having jurisdiction. I consent to jurisdiction in federal and state court in North Carolina for purposes of this Release, its enforcement and confirmation of any arbitration award.

MISCELLANEOUS//

I expressly waive any defense to the enforcement of any provision of this Release arising from a claim of lack of consideration or on any other basis. In the event that any provision of this Release is determined to be invalid or unenforceable, the remainder of the provisions shall remain in full force and effect as if this Release had been executed with the invalid provision eliminated. I understand and agree that this Release is intended to be as broad and inclusive as permitted under applicable law. The undertakings and covenants of this Release shall be binding upon me, my family, my heirs, next of kin, legal representatives, executors, administrators, beneficiaries, successors, and assigns. The Release are contractually binding and are not a mere recital.

This Release shall be effective and binding upon me. I have read this Release and understand its terms. I further represent that I am at least eighteen (18) years of age and am not a minor in my State of residence or, if I am a minor in such State, that both my parents or my legal guardian have signed this form in the “Consent” section below, acknowledging this Release and accepting its terms on my behalf. (Any personal or first person reference herein to a person waiving rights or agreeing to this waiver shall be interpreted to include parents signing such waiver for and on behalf of a minor).

I have read and agree to the Release of Liability and Medical Authorization statement above.
*

Yes No

If no, what part do you not agree with?
*

Photo and Video Release

I hereby give Wine To Water, its representatives and those acting under its authority, the absolute, perpetual, non-revocable right and permission to use any media in which my name, image, and likeness for any purpose relating to the Wine To Water mission, operations, purposes, and programming, including the promotion thereo, in any and all media throughout the world. The media shall be used at the sole discretion of Wine To Water and I waive any and all rights I may have to the media in connection with its use by Wine To Water, or the work in which it may be used. In the event such waiver should be ineffective for any reason, I hereby assign such rights to Wine To Water.

I release, discharge and agree to hold Wine to Water harmless from and against any and all liability in connection with the use of such media.

I have read and agree to the Photo and Video Release statement above.
*

Yes No

If no, what part do you not agree with?
*

Cultural Sensitivity and Contract

I acknowledge and understand that I will be working in a foreign country and that I will follow all instructions on appropriate behavior in the particular foreign country where I volunteer. This will include but not be limited to the use of alcohol, drugs, cigarettes, profanity, sexual comments, or a romantic relationship with anyone while on this trip.

I have read and agree to the Contract and Cultural Sensitivity statement above.
*